59 year old male: chest pressure

It’s a hot summer night in the suburbs, most of which you’ve spent on standby for a local baseball game. After clearing up you’re put on a chest pain call a few blocks from your quarters. The local volunteer fire department has a squad on scene which is advising you to, “continue on emergency.”

Upon your arrival you find the patient seated on the porch, on O2 via a non-rebreather, in moderate respiratory distress. The volunteer EMT relays that the patient, a 59 year old male, is having 10 of 10 chest pressure which started yesterday. He’s administered 324 mg of aspirin and withheld nitroglycerin because of the patient’s blood pressure. You’re handed a quick trip sheet as you take over patient care.

  • Pulse: 50, weak at the radials
  • BP: 80/40
  • RR: 24, labored, lungs clear and equal bilaterally
  • SpO2: 90% on room air, 94% on 15 L/min via NRB

Your partner starts putting on the electrodes for a 12-Lead while you get a quick history.

  • PMHx: hypertension, hypercholesterolemia, GERD
  • Medications: lisinopril, lipitor, omeprazole, “vitamins”
  • Allergies: penicillin, sulfa drugs, levitra
  • Last ins/outs: normal dinner

The patient appears acutely unwell, ashen gray, and diaphoretic. He states the pain is, “pretty constant now,” and that he feels it in, “my shoulder blades and running down my spine”. Your partner hands you the initial 12-Lead:

Uh Please Standby - Initial 12-Lead

The EMT helps you and your partner place the patient on your stretcher and move the patient to your unit. Your partner asks you what you think about the 12-Lead and if you’ll need a driver.

  • What does the 12-Lead show?
  • Should this patient be taken to the local hospital, about 10 minutes away, or the cardiac center, about 25 minutes away?
  • Do you need a driver?

12 Comments

  • Ekaterine says:

    inferolateral AMI, the patient should be taken to the cardiac centre, A driver is needed..

  • patrick says:

    Right sided MI go to cath. Take adriver watch pressure.

  • In a patient with chest pain – this ECG is of definite concern. I see Sinus Bradycardia ~50/minute – with more-peaked-than-usual T waves in inferior and lateral precordial leads. These are probably “hyperacute” T waves – especially since lead aVL shows the “mirror reflection” of an inverted T wave with the same broadening. The R wave in V2,V3 looks a bit taller-than-expected in association with an abnormal flat ST in V2 and subtle but definite ST depression in V3,V4 and lead I. IMPRESSION – this may be an early acute infero-postero-lateral MI (possibly early stemi-in-the-making). Clinical correlation and serial tracings are needed. With 10/10 chest pressure – acute cath is desirable for Dx/Rx. The bradycardia & hypotension are consistent with ECG findings. V1 is not particularly suggestive of acute RV MI – but given the overall picture – right-sided leads would be helpful in diagnosis since hemodynamics do suggest likely right-sided involvement.

  • jason buc says:

    So I see some worrysome signs in the EKG. The flipped T-wave in AVL, the STD in V3. Nothing says STEMI (yet). Serial 12-leads are a dead horse, no sense in beating on that. I’m taking them!
    This pt’s presentation sucks! 80/40, brady, looks like shit. for me this guys goes to the cardiac center. I think he needs it. But I can’t pin that decision to this EKG.

  • ermedic5553 says:

    Probable Inferior posterior STEMI developing. Posterior leads appear to be meeting millimeter criteria based on computerized measurements listed. With clinical picture, I don’t think this would be a “hard sell” for a receiving facility to open the lab. However, his presentation has me concerned for an aortic dissection. When is the last time you heard a patient c/o pain migrating down their back with cardiac symptoms? Wondering if a dissection at the aortic root is hitting the RCA (probably a zebra with dissection). Take a driver (if authorized), probably going to need the help. Definitely going to cardiac center. Personally, I would skip the R sided EKG at this time. We have enough already to strongly suspect R sided involvement, and not going to change pt care (unless needed to get cath lab open). Serial EKG’s, couple of big lines, apply pacer pads, consider cautious fluid boluses (250ml each w/ reassess), hold off on NTG, if O2 sats drop, consider early intubation (CPAP might drop pressure significantly). Watch for change in neuro status or limb weakness (Sudden weakness in limbs or neuro change would really up my suspecion of dissection).

  • Iain says:

    Developing inferior-posterior MI, based on V3-V4 ST depression and presentation. Needs a full right side and posterior (V4-V9) 12-lead done quickly. Treat it like a STEMI (bilat IV, morphine), though I wouldnt necessarily call for field activation unless my additional EKGs are more interesting or it changes.

    Definitely transport to cardiac center, definitely take a 3rd. Transmit and have a talk with a doc since you have 25 minutes.

  • Darren says:

    The patient is in sinus bradycardia, with a normal axis and narrow complex. R wave progression is ok. Little bit of wandering baseline can be tricky, but the morphology of the ST segments, along with the patient’s symptoms, cannot be ignored. There appears to be a slight amount of ST elevation in the inferolateral leads; whether it is enough to call a STEMI, I don’t know.
    My treatment would start with further investigation. A strong likelihood of RVI exists, so right 12 lead is a big next step. Also a good possibility of posterior involvement, so a 15 lead is needed as well. We have clear breath sounds, so bilateral large-bore IV’s with volume therapy is needed now, since ASA has been given. We also need to anticipate the possibility of worsened bradycardia; if this is an RCA occlusion, the likelihood of SA or AV nodal blocks is high. Be ready to pace if necessary. A driver wouldn’t be a bad idea at all, and this patient needs to be at a PCI equipped facility. If I’m able to get blood pressure up, I might consider LOW dose IV nitrates to attempt to relieve the patient’s pain, as well as fentanyl. Morphine is too vasoactive in this case.

  • Floyd says:

    I agree with everything Dr. Grauer stated. I would think of the r wave in v1,2 to be the posterior q wave. I am also concerned about the st depression in I&avl. Certainly likely to be reciprocal changes. While I would like to activate the cath lab I don’t think it meets the “official criteria”. I would contact my local pci capable facility and express my concerns to the er physician. He may disagree but Im sure serial 12 leads would tell the tale soon enough.

  • Jason says:

    I don’t like his presentation at all. First off..the non-machine findings…ashen, unwell, diaphoretic, pain…BP, Pulse, all put together tells me this guy is VERY sick. I might consider a chopper to the PCI facility at this point. I know it’s hard to pinpoint with the wandering baseline, but, elevation in II, III, AFV, with some depression in I and AVL (plus the downward sloping inverted T wave in AVL), and I’m calling the STEMI to the hospital. ASA, O2, Fentanyl, fluid challenge, and a FAST transport.

  • Matt says:

    Infero posterior stemi. Elevation 2, 3, avf. Depression V2, V3. Classic clinical presentation hypotension , bradycardia, pain in shoulders down back, explains posterior wall. 324 aspirin. Access will be tough due to bp IOs, ACs and/or Ejs lots of fluid. Dopamine, preferably levophed, drip to stabilize bp. He probably code in front of you be ready.

  • Lucas says:

    Besides MI and Aortic Dissection, this presentation of acute chest pain and hemodynamic compromise, associated with important dyspnea would concern me for PE, which I think should be properly investigated.

  • Inferolateral MI, not RV (T-wave down in V1)

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EMS 12-Lead

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Comments
Stuart
Anterior T wave inversions and PE.
Studies (can't remember them off the top of my head) have shown that TWI in V1-4 + III is 85% likely to be RV strain, 15% ischemia. If I see anterior TWI, the very next lead I look to is III
2014-11-23 18:00:51
Arlene R
The Trouble with Sinus Tachycardia
It has been very insightful for me as i read this post. Thanks to the may people who commented. Like many nurses, I was also taught to differentiate svt from st by rate and now I stand corrected. I have a Telemetry test coming up soon, I wont have the patient in front of me…
2014-11-20 19:59:33
Nick
100 yof CC: Rib pain and intermittent spasms
Can't be a potassium imbalance. The TW's wouldn't change and then change back. If it was coronary spasm, I would expect some ST segment elevation. The TW'S are also not hyperacute (peaked). Does she wear some sort of electronic stimulator?
2014-11-19 01:05:43
Anterior T wave inversions and PE. | EMS 12 Lead
Not just S1Q3T3: Look at the other 10 leads!
[…] Last week, I described the case of a middle-aged male with a vague history of heart failure who had been having progressive shortness of breath for 4-5 days. On the day he called 911, he had been walking a short distance when he syncoped. EMS obtained an ECG: […]
2014-11-18 18:33:47
Christine
100 yof CC: Rib pain and intermittent spasms
I believe this may be coronary artery vasospasm.
2014-11-18 11:02:45

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